Ethics in Serving Homeless Veterans

Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS, MSJHealth Care Ethicist, Ethics Consultation VA National Center for Ethics in Health Care

Michal Wilson, MD, Medical Advisor, VHA Homeless ProgramsNational Center on Homelessness among Veterans

Objectives

1. Explain the ethical justification of the harm reduction and housing first approaches

2. Describe the concepts of boundaries in healthcare in general and specific considerations for workers in the homeless program

3. Demonstrate a basic model of decision-making to help think through ethical dilemmas

4. Develop ways of balancing respect for patient autonomy and the duty to protect patients, staff, and the public from harm

The Ethical Foundation of VA HealthCare

• There are many different kinds of health care systems with varying ethical foundationsoNot-for profit guided by the ethics of serving the communityoFor-profit maximizing return for shareholdersoReligious: fulfilling the spiritual mission of the sponsoring religious

group• VA is a beneficiary system: the government and people of the United

States have made a moral commitment to care for the health needs of those who served in the military

Practical Ethical Implications of a Beneficiary System

• Veterans have a unique continuity of care in that if they are eligible and if they so choose they can receive healthcare from and within the VA system throughout their life.

• As health care professionals and a system we only exist because of, and to serve Veterans

• In 2003, VA made an additional moral commitment to prioritize the care of financially disadvantaged Veterans

• From the social justice perspective, we are the safety net for these Veterans

Harm Reduction

• Harm reduction is an explicit approach to delivering health care (especially treatment for substance use disorders) and social services with philosophical assumptions about human nature and morality

• Housing first is an example of a harm reduction strategy along with: Needle exchange Safe injection sites HIV prevention Medication assisted treatment

What are Ethical Theories and How Do they Help Us?

• Ethical theories can inform moral arguments, justify ethical decisions• Like psychology and criminal justice, ethics has models or theories

that explain why someone is a good or bad person or something is a right or wrong action

• Three major ethical theories apply to the ethical justification of harm reduction: Utilitarianism Deontology Virtue ethics

Utilitarianism

Founded by John Stuart Mill in the 19th century.A group of normative ethical theories which posits that the moral quality of an action is determined by the goodness or badness of its consequences.

Key Features Utilitarianism

• Theory calculates a cost/benefit or risk/benefit analysis to situations to determine the most ethical course of action

• The common goal of the theory is to make those decisions that maximize the greatest happiness or health for the greatest number: conversely decisions that most minimize harm.

• Thus, if benefits (happiness/good health) of a decision outweigh the costs/risks (unhappiness/poor health) of not making the decision or of an alternative decision, then that decision or action is ethical or desirable

Utilitarian Justification of Harm Reduction Programs

• Providing housing to persons still abusing substances improves their quality of life, their personal safety, and their access to social and health care services: all good things

• Refusing to provide housing to persons until they have entered treatment or obtained sobriety may result in more risk to the individual and society, poorer quality of life, and less ability to receive health care and social service: all harms

• *Utilitarianism is the primary ethical theory justifying harm reduction.

Deontology

Also known as non-consequentialism or duty-based ethics.Founded by Immanuel Kant in the 18th century.

This group of theories determine whether an action or decision is morally good or bad using a duty-based system of analysis.

Key Features: Deontology

• The theory holds that certain duties are absolute such as truth-telling and respect for persons and individual autonomy

• Universal duties are expressed through maxims that apply in particular situations such as “do not lie” and “treat others as you would want to be treated”

• These maxims are only rational if they apply to everyone, everywhere, always; actions are only ethical if they are done for the sake of duty, that is for the right reason.

• Deontology teaches that human beings have innate dignity and worth and thus must be treated as ends in themselves not as means to other goals.

Deontological Opposition to Harm Reduction

• Treats the individual as a means to the goal of improved public health rather than as an end in themselves

• Does not hold the individual accountable for their actions, thus not respecting them as a responsible moral agent

• Facilitates and even promotes risk-taking activities that do not respect the intrinsic worth of human life

• Encourages dependency rather than autonomy

Virtue Ethics

Rooted in the ethics of Aristotle

Emphasizes the character and habits of the person performing the action not the action itself,

Key Features Virtue Ethics

• Ethical decisions are grounded in qualities or traits of character such as courage and temperance

• There are hierarchies of virtues and vices: with the optimal course in the mean

• Actions are right and good only if and when they are consonant with what a virtuous person would do in a similar situation

• We recognize what is good through imitating good people, following role models

Virtue Ethics Application to Harm Reduction

• In general virtue ethics would support harm reduction approaches as expressions of compassion to limit suffering

• Housing first and other HR interventions show the individual that the health care professional is trustworthy and altruistic

• This trust and compassion forms the basis of a relationship that can lead the individual to imitate these qualities and live a more healthy life

Boundaries in the Homeless Program

• Boundaries in the homeless program are far more fluid and flexible than in other types of social work or mental health care

• Harm reduction is a person-centered treatment in which workers form close relationships with patients often visiting them in their homes, meeting with them in public places, assisting them with practical activities.

• The Veterans served are often among the most vulnerable, resilient, challenging and under resourced of Veterans in any other program in the system

What is a Boundary Anyway?

• Ethical principles, laws, and professional values that “bound” the professional-patient relationship

• Boundaries are “limits” that indicate behavior that is not acceptable

• They are also directives and guidelines that recommend what behavior is appropriate

Why Do We Need Boundaries?

• To enable vulnerable patients to place their privacy, health, very life in the hands of professionals and to trust they will do good and not harm

• To provide structure to protect patients from being exploited because of the unequal power and knowledge in the professional relationship

• To reduce and operationalize dual relationships and conflicts of interests in small communities and rural areas

What Would Happen Without Boundaries?

• Patients would not know what to expect of professionals

• Professionals would not know where the line between their own interests and that of patients should be drawn

• Without a higher standard of conduct, health care and the other professions would soon become like any other job

Where Do Boundaries Come From?

• All professions have Codes of Ethics

• State licensing boards

• State laws & federal regulations

• VA Policy 5CFR, Part 2635, “Standards of Ethical Conduct for Employees of the Executive Branch”

• Other hospital and facility policies

• Consensus statements of professional organizations

Boundary Crossings and Boundary Violations

• Boundary crossings are behavior that has the potential to, but does not necessarily go beyond, the limits of acceptable professional conduct

• Boundary violations are behaviors that breach the bounds of appropriate professional behavior

• In rural areas or small communities or special programs and positions like the homeless program overlapping or dual relationships may be boundary adaptations in those contexts but boundary crossings or even violations in other settings

The Characteristics of Boundary Violations

• They compromise professional judgment and objectivity

• They place either self or another interest above that of the patient

• They create a conflict of interest and dual roles

• They compromise the trust between patient and professional

The Consequences of Boundary Violations

Rupture of therapeutic relationship

Loss of patient and public trust

Limitations on practice

Reprimands or censures in record

License suspended or revoked

Lawsuits for malpractice and battery

Criminal charges for sexual conduct in some jurisdictions

Recognizing Boundaries

Could this activity cause others to question my professional integrity?

Would I want my other patients, other professionals or the public to know that I engage in such activities?

Is this activity a normal, expected part of practice for members of my profession?

Might engaging in this activity compromise my relationship with my patient?

There is no Black and White Boundary Line

• Except for clear boundary violations, boundaries are grey. Each situation must be examined on a case by case basis

• In rural areas or other small communities or homeless programs, boundaries must be contextualized

• For example a social worker in a mental health clinic should probably not be visiting patients in their apartment but this would be an expected part of a homeless worker’s job

Ethical Dilemmas

• The greyness of boundaries creates ethical dilemmas for health care professionals

• Ethical dilemmas occur when there are two or more ethical values or principles that cannot be equally fulfilled or followed.

• Ethical dilemmas often involve a conflict or uncertainty about values: the classic dilemma in the homeless program is wanting to keep an individual safe from harm but also wishing to respect choices that may place the person at risk.

• Dilemmas are resolved through balancing, specifying and weighing the principles

Ethical Principles

Doing good (beneficence)

Preventing harm (nonmaleficence)

Respecting right to make own decisions (autonomy)

Treating those who are alike similarly and those who are important differences differently (Justice)

Law & Ethics

Law

• Is the “must”

• It often overlaps with ethics

• For example: if an individual due to the use of substances of abuse is neglecting or abusing a child it is both legally required and ethically appropriate to report to child welfare authorities

Ethics

• Is the “should” or ”ought”

• At times ethics and law conflict

• We would not normally call the police and tell them a patient is using methamphetamine even though doing so is illegal and not something which we think is a good thing to do

National Center for Ethics in Health Care Quality Check for Ethical Decision-Making Process

• Do I have all the important facts relevant to the decision?

• Have I involved everyone who should be part of this decision?

• Does this decision reflect organizational, professional, and social values?

• Do the likely benefits of the decision outweigh any harms?

• Will this decision keep the problem from recurring or establish a good precedent?

• How would this decision look to someone outside the organization?

Case 1: Safety First

• A 35-year old combat Veteran Mr. R is drinking heavily and allowing prostitutes to stay in his HUD-VASH housing

• Mr. R has previously lost a placement due to this behavior

• One night when very drunk Mr. R shoots off a gun in his apartment complex and the police are called

• How should the homeless team handle this situation?

Case 1: Safety First Ethics Consultation

The workers first duty is to protect themselves and the public. There may be times when it is not safe for the worker to visit Mr. R. This does not mean abandoning him.

The workers should continue to try and provide case management including educating him about the potential negative consequences of his behavior, such as losing his housing or going to jail.

There may also be other ways the worker can continue to help the veteran such as connecting him with the Veterans Justice Outreach and/or Substance Use programs.

Case 2: We Can’t Let this Happen

• Ms. S has bipolar I, and when taking her medications is a bright, kind and artistic woman who has been a success story for the local homeless program.

• On a routine visit the worker finds several unopened bottles of lithium and Ms. S lying in bed in the middle of the day, with dirty dishes stacked in the sink; she admits to not taking her medication for two weeks and being depressed but not suicidal.

• Ms. S declines to go into the clinic or emergency room and so the worker calls Ms. S’s psychiatrist and tells him “We can’t let this happen, you need to put her in the hospital.”

Case 2: We Can’t Let this Happen: Ethics Consultation

Patients with capacity have the right to refuse treatment. Even when we know those refusals will likely have a bad outcome

Under the mental health codes of almost every state a patient who is not at imminent risk of self or in some jurisdictions grave passive neglect cannot be compelled to seek psychiatric care against his will

Respect for the patient’s autonomy outweighs the risk of harm but the case manager can continue to visit the patient to encourage them to seek treatment voluntarily as well as notifying the psychiatrist if Ms. S’s condition worsens

Case 3: Heat versus Music

• Mr. F is 65-year old Veteran with multiple medical problems including diabetes is living in a small shed with no utilities.

• The HUD-VASH program has offered Mr. F several apartments which he has declined saying he does not want to use more of his small income for rent than he currently pays for the shed.

• Winter is approaching and Mr. F continues to tell the homeless workers he would rather use his money to by CDs and book.s

• The homeless workers feel a lot of moral distress about Mr. F and wonder if they can compel the patient to accept safer housing?

Case 3: Paternalism & Autonomy Ethics Consultation

The homeless workers are wishing to act out of what is technically called “soft paternalism” defined as the ”overriding of a person’s actions or decisions for his own good”

If the patient has decision-making capacity, then both law and ethics say he is able to make ”bad” choices even if they endanger him

From the Veteran’s perspective, what is good is being able to spend his money on entertainment not rent and so acting on the Veteran’s values the case manager might work on a budget with Mr. F that would enable him to pay rent on a livable unit while still buying entertainment on a smaller scale.

While the workers have to respect his autonomy to live in the shed, but they can continue to try and persuade him to accept other housing and explore ways to make his current situation more livable.

When in Doubt, Give a Shout for Help

• Trusted colleagues may provide and objective view

• Develop supervisory strategies even long distance

• Specialty consultants through electronic means

• University, state or institutional ethics consultants or committees

• State laws and regulations

• Practice standards

• Empirical ethics articles

• Professional guidelines

Ethics Resources

• Every VA facility has an Integrated Ethics Program that includes an Ethics Consultation Service available to provide consultation to staff, families and patients

• The National Center for Ethics in Health Care also has a National Consultation Service that works closely with these facilities

• For more information https://www.ethics.va.gov/activities/consult.asp